CMCG Forms

CMCG New and Returning Patient Form

Step 1 of 3

Who may we thank for referring you to us?
Name*
First Last
What is your date of birth (DOB)?*
MM
DD
YYYY
Age:*
Last 4 Digits of SSN:*
What is your address?*
Street Address City State / Province / Region ZIP / Postal Code
What is your email address?*
What is your home or cell phone number?*
What type of message can we leave at this number?*
- Detailed message
- Doctor's name and number
- Do not leave a message
What is your work number?
What type of message can we leave at your work number?
- Detailed message
- Doctor's name and number
- Do not leave a message
Name of Employer:
Address of Employer:
Street Address City State / Province / Region ZIP / Postal Code
Occupation:
Nearest Friend or Relative (not living with you):*
First Last
Phone:*
Emergency Contact:*
First Last
Phone:*
Relation to Patient:*
What is the phone number of your preferred pharmacy?

Parent's Name:
First Last
Parent's Date of Birth:
MM
DD
YYYY
Parent's Age:
Parent's Social Security #:
Parent's Address (if different from dependent's):
Street Address City State ZIP Code
Parent's Home or Cell Number:
Parent's Work Number:
Parent's Employer:
Parent's Employer's Address:
Street Address City State ZIP Code
Parent's Occupation:
Spouse's Name:
First Last
Spouse's Date of Birth:
MM
DD
YYYY
Spouse's Age:
Spouse's Social Security #:
Spouse's Address (if different from patient's):
Street Address City State ZIP Code
Spouse's Home or Cell Number:
Spouse's Work Number:
Spouse's Employer:
Spouse's Employer's Address:
Street Address City State ZIP Code
Spouse's Occupation:
Primary Insurance:
Insurer's Address:
Street Address City State ZIP Code
Insurer's Phone Number:
Name of Insured:
Relationship to Patient:
ID Number:
Group Number:
Secondary Insurance:
Insurer's Address:
Street Address City State ZIP Code
Insurer's Phone Number:
Name of Insured:
Relationship to Patient:
ID Number:
Group Number:
Do you want to exercise your insurance lab benefits and have AEL bill your insurance for any lab work done?*
- Yes
- No
I understand CMCG billed lab charges are not eligible for insurance reimbursement (please initial):*

HIPAA
I. AUTHORIZATION FOR TREATMENT AND ASSIGNMENT OF BENEFITS
I do hereby consent to medical evaluation and treatment by my physician, physician representatives and technicians. In the case of diagnostic studies, laboratory tests, psychology and physical therapy treatment, as prescribed by my physician, I hereby consent to treatment by the technologist, physician and mid-level providers (and their representatives).

I do hereby authorize Germantown Aesthetics (GA) to release to any third party payer (such as an insurance company or government agency) any necessary medical and/or psychiatric information and records concerning diagnosis and treatment when requested by such a third party for use in determining payment for medical services.

I do hereby authorize payment directly to any GA Provider examining and/or treating me, from any group or individual medical benefits herein specified and otherwise payable to me for their services.

I certify that the information given to me in applying for payment under the Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Health Care Financing Administration, Social Security Administration/Division of Family Services, Blue Cross Blue Shield of Tennessee, Medicare or its intermediaries or any other carriers any additional information needed for this or a related Medicare claim. I hereby certify that all insurance pertaining to treatment shall be assigned to the GA provider treating me.

I permit a copy of these authorizations and assignments to be used in place of the original, which is on file with GA. I understand this is a lifetime authorization remaining in effect until revoked by me in writing.

I agree that payment for professional services is due and payable when services are rendered. I agree that should the amount of the insurance benefits be insufficient to cover the amount of the claim, I will be responsible for payment of the balance of my account for any professional services rendered. I agree to be responsible for any co-payment and/or deductible associated with my insurance policy. I understand a $10.00 billing fee will be charged for co-pays and deductibles not paid at time of service. I also understand GA will help in billing my insurance company for payment but it is my responsibility to follow-up on any claim submitted if any payment is not received in a reasonable amount of time. A finance charge of 1.5% periodic will be added to all patient account balances left outstanding for more than 30 days. I agree that I will be responsible for any collection fees if it becomes necessary to send my account for collections. I agree that I will be responsible for any fees for returned checks.

II. USE AND DISCLOSURE OF HEALTH INFORMATION
Pursuant to the requirements found in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the following is offered for your information and consent. Please be aware that it is this corporation’s policy to require your reading and signing this consent form prior to the provision of treatment or any other medical services. If you have any questions, please ask for the Privacy Officer of this corporation.

I do hereby consent to the use and disclosure of my individually identifiable health information (“Health Information”) by Germantown Aesthetics (GA) and its Professional Providers (“Provider”) for the purposes of providing treatment to me, receiving payment from responsible parties for health care services rendered by the Provider, and/or engaging in health care operations, such as office management, credentialing, case management, and quality assessment. This authorizes the release of my Health Information or copies of such to be transferred to myself and/or any physician that I am referred to by a GA Provider.

I understand that Provider’s Notice of Privacy Practices (“Notice”) describes in more detail the types of uses of disclosures of Health Information involved in treatment, payment or health care operations, and that I have a right to request and review such Notice prior to signing this consent.

I understand that the Provider has reserved the right to change its privacy practices as described in the Notice. In the event of any change in the Provider’s privacy practices, Provider will revise the Notice. I understand that I can obtain a copy of the revised Notice by writing to Provider.

I understand that if I choose to not sign this consent, Provider may withhold medical services, other than emergency services.

I understand that I have the right to request a restriction (ask for and see Patient Authorization to Use/Disclose Health Information) on Provider’s use or disclosure of any and/or all Health Information to any and/or all locations, entities, or persons (including family members I wish to have or not have access to my Health Information). I further understand that Provider is not obligated to agree to my request. However, if Provider does agree to my request, the agreement will become binding.

I understand that I have the right to revoke this consent, in writing, at any time, except to the extent that Provider has relied on this consent, and that any revocation will become effective on the date it has been received by Provider and will apply to uses and disclosures of the Health Information after the date of receipt.
Do you accept the HIPAA agreement?*
- I accept the agreement
- I decline the agreement
MEDICAL PROFESSIONAL LIABILITY ARBITRATION AND PRIVACY AGREEMENT

This arbitration document is meant to preserve your rights AND maintain the responsibility that the staff Physicians of Germantown Aesthetics; div of MVAG, Inc., have for you. You are invited to discuss any portion of this agreement with any of our staff or an attorney before your surgery.In consideration of the agreement of:

I. Germantown Aesthetics; div of MVAG, Inc.

II. The Surgeons of Germantown Aesthetics; div of MVAG, Inc.

III. The Medical Director of Germantown Aesthetics; div of MVAG, Inc.

IV. The staff under contract with Germantown Aesthetics; div of MVAG, Inc. (Including those individuals under lease service agreement from any third party staffing entity): herein called the “Providers,” to render certain medical and surgical services for hereinafter named patient, the providers and patient do hereby agree as follows:

(1) It is understood that any dispute as to medical malpractice, that is as to whether any medical service rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the laws of the State of Tennessee, TN Code Ann. § 29-5-302 (1980), and not by a lawsuit or resort to court process except as the law of the State of Tennessee provides for judicial review of arbitration proceeding, both parties to this contract, by entering into it, are giving up their right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

(2) In the event of any claim, demand, controversy, civil action or dispute, including but not limited to personal injury, malpractice, or any tort, whether brought in tort, contract or otherwise, by Patient, his dependents, whether or not minors, heirs at law, or person representatives, against Doctor or any of Doctor’s officers, directors, shareholders, agents, representatives, employees, successors in interest, assigns, staff physicians or associates agreeing in writing to be bound by this arbitration provisions of the agreement (“Affiliates”) THE SOLE METHOD FOR RESOLVING SUCH DISPUTE SHALL BE BY BINDING ARBITRATION ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION in accordance with the Commercial Arbitration Rules of the American Arbitration Association(AAA). The parties hereby agree that they shall submit their controversy to a neutral arbitrator provided by the AAA, who shall decide the controversy based on the evidence presented. The arbitrator will be agreed upon by mutual consent of the parties. It is agreed that all parties relevant to a full and complete settlement of any dispute subject to this agreement may be interviewed or joined. The parties further agree that the commercial arbitration rules of the American Arbitration Association (AAA) shall govern all arbitration conducted pursuant to this Arbitration Agreement.

(3) The prevailing party in any arbitration pursuant to this agreement shall be all cost, including reasonable attorneys’ fees and the arbitrators’ fees, in prosecuting or defending the claim in arbitration, but not to exceed $2,000.00 in amount. Furthermore, if any action is initiated or undertaken to set aside or otherwise attack this arbitration agreement or award, or to compel arbitration, the prevailing party in the court action shall be entitled to all costs of such action, including reasonable attorney’s fees as may be fixed by the court.

(4) Any party initiating arbitration under this agreement shall file with his/her petition a bond or cash surety in the amount equal to One Thousand Dollars ($1,000.00), which shall provide security for attorney’s fees and costs in the event that the moving party should not prevail.

(5) In the event that any provision of this agreement shall be void or unenforceable for any reason whatsoever, then such provision or provisions shall be stricken and shall be of no force and effect. The remaining provisions of this agreement, however, shall continue in full force and effect, and to the extent required, shall be modified to preserve their validity.

(6) This agreement shall not limit the ability of the physician, in the exercise of his professional judgment, to refer the patient to other physicians or to decline further medical treatment to the patient.

(7) Further, it is understood that a patient’s medical information will be considered private, and will only be released after the presentation of a signed patient request. Even though HIPAA statues do allow for covered medical entities to release information to other covered entities, the privacy standard of the Providers is stricter, and private information will NOT be released to other HIPAA entities without the permission of the patient. Likewise, the patient agrees to protect the trade and reputation of the Providers by extending a similar level of consideration. Only permissible avenue of dispute resolution is the binding arbitration process, and the patient agrees to make no publications or statements - public or private, written or oral - which would harm the trade of the Providers. A violation will result in damages of no less than $20,000.00. By statute, the results of any Arbitration finding may become a matter of public record.

(8) This agreement shall be construed in accordance with and governed by the law of the State of Tennessee. THIS IS A BINDING LEGAL DOCUMENT, WHICH MAY HAVE AN IMPORTANT EFFECT ON YOUR LEGAL RIGHTS. THIS AGREEMENT PROVIDES THAT ALL MEDICAL CONTROVERSIES SHALL BE DECIDED BY AN ABITRATOR AGREED UPON MUTUALLY. CONSULT YOUR ATTORNEY ON ANY QUESTIONS YOU MAY HAVE. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE ONE (1) OF THIS CONTRACT
Do you accept the arbitration agreement?*
- I accept the agreement
- I decline the agreement
By typing your name and today's date below, you indicate that you:
• have read and agree to the HIPAA and Arbitration Agreements
• have received a copy of the HIPAA and Arbitration Agreements
• have provided truthful information to Germantown Aesthetics
You may download a copy of these agreements for your records:
HIPAA
ARBITRATION AGREEMENT
First and last name:*
Today's Date:*
Date Format: MM slash DD slash YYYY

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Cosmetic Surgery in Germantown & Memphis, TN

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CMCG Forms

CMCG New and Returning Patient Form

Step 1 of 3